J Adv Environ Health Res (2020) 8: 133-142 DOI: 10.22102/jaehr.2020.222976.1163 ORIGINAL PAPER

The assessment of environmental health status in the route of Arbaeen pilgrims at Shalamcheh border in southwestern

Rouhollah Shokri 1, Ali Almasi 2, Jafar Rabihavi 1, Seifollah Ganjali Dashti1, Hashem Hajiveisi3, Ali Asghar Valipour1, Mitra Mohammadi4, Amir Hossein Mahvi5, Majid Hashemi6,7, Shima Rezaei8,, Azimeh Karimyan1, Sharareh Zovedavianpour1

1. Abadan Faculty of Medical Sciences, Abadan, Iran 2. Department of Environmental Health Engineering, School of Public Health, Social Development and Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran 3. Health Network of Sanandaj, Kurdistan University of Medical Sciences, Sanandaj, Iran 4. Department of Environmental Health Engineering, Faculty of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran 5. Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 6. Environmental Health Engineering Research Center, Kerman University of Medical Sciences, Kerman, Iran 7. Department of Environmental Health, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran 8. Department of Environmental Health Engineering, Environmental Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran

Date of submission: 10 Mar 2020, Date of acceptance: 05 Aug 2020

ABSTRACT The negligence of health regulations in the preparation of the foods, services, and sanitary and welfare facilities provided in religious borders could increase the risk of waterborne infectious intestinal diseases. Therefore, the continuous monitoring and control of health indicators is essential in mourning borders. This descriptive, cross-sectional study was conducted on the Mawkebs of Shalamcheh border (n=267). In total, 186 samples were evaluated in terms of the microbial quality of water, and 66 samples were evaluated in terms of the microbial quality of food. The studied parameters in drinking water included the residual free chlorine, pH, turbidity, total coliform, and fecal coliform, and the studied parameters in foodstuffs included the total count and fecal coliform (Escherichia coli). According to the findings, these indicators were appropriate in terms of accommodation hygiene and preparation and distribution of crew hygiene by 99.9%. On the other hand, there were zero cases where the food sampling results were undesirable for the measurement of the total count and fecal coliform. The number of the contaminated water samples was 46 (24.7%) out of 186 water samples. Therefore, the proper implementation and continuous control of health instructions seem critical for these borders, and it is suggested that special regulations and indicators be enacted for the crew in charge, so that they would attend training courses, obtain medical examination cards, and practice personal hygiene. Keywords: Environmental health, Food hygiene, Water quality, Arbaeen

 Shima Rezaei assessment of environmental health status in the route of [email protected] Arbaeen pilgrims at Shalamcheh border in southwestern Iran. J Adv Environ Health Res 2020; 8(2): 133-142 Citation: Shokri R, Almasi A, Rabihavi J, Ganjali Dashti S, Hajiveisi H, Valipour AA, Mohammadi M, Mahvi AH, Hashemi M, Rezaei S, Karimyan A, Zovedavianpour Sh. The

MUK-JAEHR 134 Shokri et al.

Introduction Infectious diseases are a common health The World Health Organization (WHO) issue in mass gatherings, especially in case of defines mass human gatherings as the presence the lack of preparedness in healthcare systems. of more than 1,000 people in a specific location Since Iran is one of the most important at a specific period. Accordingly, the largest countries on the walking path of Arbaeen and mass gatherings in the world are Hajj and plays a key role in the provision of the health Arbaeen rituals, both of which are related to services to pilgrims, the experience of health Muslims, with the latter performed for the challenges by pilgrims is of utmost martyrdom of Hazrat Aba Abdullah Al- importance.7 Several studies have been Hussein (AS).1 focused on the environmental health of various Arbaeen pilgrimage is one of the locations.8 During the inspection of the largest religious gatherings in the world, which environmental health of the food stores and takes place 40 days after the anniversary of the warehouses related to the military units in martyrdom of Imam Hussein (AS), the third Tehran province (Iran), the status was reported Shiite Imam. Every year, a huge crowd of to be unacceptable, while indicators such as the pilgrims travel to the city of Karbala for location and duration of storage were pilgrimage to Imam Hossein holy shrine in considered favorable.5 Karbala on Arbaeen day, with the main route Another research in this regard aimed to starting within 80 kilometers from Najaf.2 assess the bacterial quality of the drinking According to the statistics reported in 2019, the machines of the intercity buses in Bushehr port number of the Iranian pilgrims attending in 2010 within a three-month period, and it was Arbaeen pilgrimage was 3,800,000, while reported that the level of residual chlorine was more than 3,000 foreign pilgrims from across zero in 97% of the cases. On the other hand, the borders of Iran also attended Arbaeen the fecal coliform and total coliform values pilgrimage.3 Along the route, free service were above the threshold in 8.8% and 12.5% stations (Mawkebs) are voluntarily set up in of the cases, respectively.9 The inspection of order to provide services and medical and the food and salad samples of four military welfare facilities to the pilgrims. These restaurants also indicated that five sample stations are highly important from the health cases were infected by Escherichia coli (E. and economic perspective, and it is essential to coli), while none of the samples was reported properly determine the environment health to contain Salmonella.10 indicators based on weather conditions, zone Given the discussed background climate, location conditions, and saved food regarding the health of Mawkebs and its types.4, 5 importance, the exact investigation, Free service stations are roofed spaces inspection, and continuous control of the with terraces or canopies and an elongated production, distribution, and presentation yard (with or without fence). These stations centers of edible, drinkable, cosmetic, and could be categorized by factors such as size, health materials conforming the Article 13 facade, and language. They are located at the amendment regulation are paramount. In the intersections of battle zones, important current research, we investigated the checkpoints, and entrances/inside of cities. In environmental health indicators of Mawkebs war-torn cities, these stations are mainly to determine the health status of drinking located in the side places of mosques, while in water11 in terms of the microbial quality, the suburbs, temporary buildings (mainly wastewater disposal and collection,12 disposal single-storey) are built or second-hand methods of solid wastes, sanitation of sanitary containers are used to set up the stations. facilities (e.g., drinking machines, WCs, However, the facilities of these stations are not bathrooms, wash basins),8 the presence of the same everywhere, and the space and vectors in temporary settlements and along the quality vary.6 routes, and microbial characteristics of the

MUK-JAEHR J Adv Environ Health Res (2020) 8: 133-142 135 food distributed in Mawkebs at Shalamcheh standards. border as one of the marching routes of The present study aimed to assess the Arbaeen, so that we could take a step toward environmental health status on the route of maintaining the health of the pilgrim Arbaeen pilgrims on the Shalamcheh border. community by providing a clear scientific and statistical picture of the environmental health Materials and Methods status and presenting the results to the relevant This descriptive, cross-sectional organizations to develop effective study was conducted on 267 Mawkebs on the interventions for the improvement of the status Shalamcheh boarder. Fig. 1 depicts the and comparison of the results with the geographical location of the study area.

Fig. 1. Location of the study area

Shalamcheh border terminal is located in personal hygiene, chapter two is focused on the in southwestern Iran on construction and health conditions for food the common border between Iran and . The preparation, production, distribution, storage, distance of this border to in and sale of restaurants and public places, Khuzestan province is 15 kilometers and 150 chapter three is on work equipment, chapter kilometers from , the capital of the four is on the duties of local health officers, province. Notably, Basra is the nearest city of supervisors, and duty officers, and chapter five Iraq to this border, which is located at the is focused on the classification of places, distance of 30 km.2 In the present study, we centers, workshops, and factories in terms of visited the location to evaluate the health the inclusion of materials in this regulation. conditions conforming to the standard Data were partly collected via direct checklists of the Iranian Ministry of Health sighted reports and interviews with authorities (Article 13 of the law on foods, beverages, and crew. The Mawkebs were assessed by four cosmetics, and hygiene). The amendment to general indicators, including: 1) the food the Article 13 of the law on foods, beverages, production and distribution hygiene, 2) health, and cosmetics was approved by the drinking water hygiene, 3) accommodation Islamic Consultative Assembly in December hygiene, and 4) health of crew on food 2000 and contains five chapters, 95 articles, 54 production, processing and distribution. The notes, and 46 paragraphs. Chapter one is on health status of the pantries and kitchens and

MUK-JAEHR 136 Shokri et al. their crew, toilets, sewage disposal conditions, to 1% and bread is one of the major sources of and food production and distribution was salt intake in Iran, the salt value was rapidly evaluated, as well as the awareness of the crew tested using Salt/TDS tester. In case of high and servants regarding the environmental salinity, the consequences of the excessive use health concerns and presence of health of salt (e.g., hypertension) were described to verification cards.8 decrease their prevalence in the long run. In the present study, 186 water samples and 66 food samples from the Mawkebs were Surface contamination sent to the laboratory for microbial tests. The Rapid surface analysis was performed studied parameters of drinking water included using rapid portable surface test equipment. the residual free chlorine, pH, turbidity, and The ranges of microbial contents were total and thermoduric coliform. In addition, the categorized based on the RLU, and RLU of studied parameters of food were the total count less than 10 was defined as a non- and E. coli. At this stage, portable equipment contaminated environment, while the RLU of such as salinity meter, injection thermometer, 15-40 was defined as an alarming level, and pH meter, hygrometer, oil, and surface and RLU of ≥40 was described as contaminated. aflatoxin evaluators were used to evaluate food hygiene. Injection thermometer An injection thermometer is used to Total Polar Material (TPM) measure food temperature. The critical range In the present study, the oil evaluator for food products is 4-60 °C, and the products device (Atago, Japan) was used, which is a should be preserved at temperatures below 4 manual equipment for the rapid testing of °C or above 60 °C. cooking oils and is capable of measuring the polarity, fatty acid value, and temperature of pH meter oil. Total polar material (TPM) shows the To detect the baking soda in food aging of oil due to temperature. As the polarity products, the pH of below 6.4 in the samples increased along with oil aging, the ranges was considered acceptable, and the pH of presented in Table 1 were categorized by the above 6.4 was considered unacceptable. TPM percentage value. Aflatoxin Table 1. TPM waste oil range Due to the poisonous effects and Qualitative Interpretation Percentage carcinogenicity of aflatoxins, these Without contamination -14% Warning limit 14-24% compounds must be evaluated and detected in Contamination More than 24% various food products. The permissible limit of aflatoxins in human food has been set at 50 The researchers confirmed that the polar ppm by the Food and Drug Administration parts that were removed from the oxidized oil (FDA). exerted poisoning effects on animals, and it is recommended that oils with more than 24-27% Hygrometer of TPM be removed. The legal limit point for According to the findings, the optimal the oils has been set at 25%.13 On the other humidity of the food stores that have been hand, free fatty acids are used for the detected with Hygrometer was within the evaluation of oils during the storage period and range of 55-65%. The Microsoft Excel are not suitable for assessing the impact of software was used to describe the obtained temperature on the oil. data.

Salt/TDS tester Results and Discussion As the standard salinity of bread is limited The present study aimed to assess the

MUK-JAEHR J Adv Environ Health Res (2020) 8: 133-142 137 environmental health status on the route of the indicators is critical.14 Fig. 2 depicts the Arbaeen pilgrims at Shalamcheh border. To number of the free service stations versus the maintain the health of the pilgrims who travel inspection visitors per day. As can be to holy shrines, the supply of healthy water, observed, the number of the stations increased food, and settlement in accordance with health while nearing to Arbaeen day.

700 Total of free station 600 Visited free station 500 400

Namber 300 200 100 0

Date

Fig. 2. Number of free service stations and number of visits per day

Pilgrims' settlement locations 120 Inspected pilgrims' settlement locations 100

80

60

40 Namber 20

0

Date Fig. 3. Total number of pilgrim accommodations and inspections per day

As there were Mawkebs with more than settlement in each Mawkeb, and the difference one visit per day, the number of the visited in the number of the inspections with the station per day was observed to be more than number of the Mawkeb was due to the multiple the stations on the same day in the current inspections of the Mawkeb per day. The research. In general, the obtained results inspections also revealed that 99.9% of the indicated the proper status of Mawkebs in accommodations were healthy. terms of health. Fig. 3 shows the number of the In the current research, the inspections inspections from the accommodations per day. indicated that all the WCs were cleaned on a As is depicted, the number of the settlement daily basis and had proper health conditions. areas varied depending on the population. In Furthermore, the recommendations of the addition, spacious tents were set up for health manager were properly implemented,

MUK-JAEHR 138 Shokri et al. and 99.9% of the WCs and bathrooms were contamination. The foodborne diseases caused properly healthy. In the studied stations in the by microorganisms are a major public health present study, some disinfectants (e.g., concern.18 Unhealthy foodstuff preparation, halamid and perchlorine powders) were also production, and distribution, as well as the lack used to disinfect and remove the surface of food evaluation and supervision systems contaminations of the sanitary services. In could lead to gastrointestinal diseases.7 order to control insects, rodents, and vectors, Considering the high prevalence of 2.5% permethrin and 10% cypermethrin foodborne diseases and their increased poisons were used. importance during distribution in public, the In a study in this regard, Masoumbeigi et negligence of health recommendations al. assessed the sewage disposal, reporting its increases the risk of intestinal diseases and proper status in some military centers. The may even lead to epidemics among pilgrims, presence of a sewage network was a proper and the consequences not only harm these indicator of health in the studied cases of the individuals, but they also threaten their local current research. This was also considered to community when they return home.14, 2 be the highest scored indicator in the WHO Therefore, the managers of mourning boards evaluations in this regard.15 In the current are expected to care about the food production research, each Mawkeb or adjacent Mawkebs process using simple, yet important health implemented septic tanks to dispose of the issues. During the current research, direct sewage that was discharged by sludge trucks supervision by the managers was when needed, and the status was observed to recommended for the food production process. be properly healthy. The practice of personal hygiene and having To maintain the health of the pilgrims, health registration medical examination cards some health recommendations about the were also evaluated in the managers of food disinfection of WCs and bathrooms, solid distribution. waste collection, discharge of septic tank, As huge places such as Mawkeb kitchens firefighting equipment of station and first-aid produce large amounts of corruptive wastes, kit, and water chlorination were also presented constant control must be imposed for the in addition to direct control.8 The results disposal of these wastes.19 In the current obtained by Zazouli et al. regarding the research, special solid waste trucks equipped environmental health status of mosques and with leachate gathering systems were holy places in Amol city demonstrated that employed for this purpose on a daily basis. 69.9, 68.7, and 47% of the mosques, mourning Considering the direct correlation between the places, and holy shrines had a favorable status, implementation of health regulations by the respectively.16 Also, the results of the crew and the corruption of food,4, 5 the limited evaluation of the health status of the mosques knowledge regarding food protection could and holy places in Sari (Iran) in 2016 revealed damage the pilgrim crowd irreparably. As that the private health level of the individuals such, the crew in charge of food production in the mosques was relatively low although it and distribution must be extremely careful of is highly critical. Furthermore, the mosques in health. Sari are structurally moderate and have Fig. 4 shows the total number of the food moderate equipment. In general, the mosques production places and daily inspections in the in Sari have been reported to have a lower studied area. The public food production health level than expected.17 centers also varied as they may have been inspected several times per day. Foodstuffs The results of the present study indicated Food hygiene and safety is an important that the health status of the food production principle for the prevention of human diseases centers was suitable in 99.9% of the cases, and and protection of the environment against the crew in charge practiced personal hygiene,

MUK-JAEHR J Adv Environ Health Res (2020) 8: 133-142 139 and the food production and distribution Fig. 5 depicts the results of food sampling. procedures were completely healthy as well.

250 Food production centers Inspected food production centers Inspected food distribution places 200

150

100 Number Number

50

0

Date Fig. 4. Number of food production centers and inspections

20 Total number of food sampling 18 Food sampling with favorable result 16 14 12 10 8

Number Number 6 4 2 0

Date Fig. 5. Number of food samples and samples with favorable results

As is shown in Fig. 5, all the samples are diaries (9.84%) for E. coli contamination, and evaluated as proper, and no unacceptable cases sweets (4.81%) and diaries (0.39%) for severe were reported. During the inspections, no staphylococcus contamination, respectively.20 suspicious food was eliminated, and the In addition, the evaluation of the health statistics recorded no cases of food poisoning. indicators at the hotels in Qom (Iran) indicated In the study by Faramarzi et al., the assessment that 35.5% of the cases had a proper health of food production for mesophilic bacteria status, while 54.8% were included in the demonstrated that salads (50%) and protein rehabilitation indicators, and 9.7% were products (6.36%) had the highest contaminated considered to be undesirable.21 cases, while the highest to lowest According to the information in Table 2, contamination rates were observed in sweets approximately 88.8% of the oils had a suitable (13.46%) and protein products (1.73%) for status, which was equal to 175 out of 197 cases coliform contamination, salads (58.33%) and with the TPM of less than 14%. And also, the

MUK-JAEHR 140 Shokri et al. results detected by Salt/TDS tester show the In another research conducted in Isfahan salinity exceeded 1% in 27 (21%) out of 128 (Iran), Zangiabadi et al. evaluated hotels with samples. Investigation for surface restaurants, and the environmental health contamination revealed the contamination status in 9% of the units was reported to be level of the equipment and environment was excellent, while favorable status was observed suitable in 40.5% of the cases. In addition, 21 in 45%, moderate status was reported in 36, out of 57 samples had acceptable and 9% of the units had a poor status.22 humidity. According to the information in this Table, the food samples were considered Water suitable in terms of aflatoxin production. In the Water is the most important and most current research, the percentage of desirable consumed material during a trip, which mainly results measurement with injection contributes to digestive diseases among thermometer was achieved in 74.7% of the travelers if contaminated. Fig. 6 shows the cases. In total, 96.3% of the samples were number of the drinking water reservoirs for the properly included in this range for pH. pilgrims and inspected reservoirs per day.

Table 2. Tests implemented on food products, number of samples, and percentage of desirable samples Percentage of desirable Parameters Total number of samples Number of desirable samples results Total Polar Materials (TPM) 197 175 88.83249 Salt/TDS Tester 128 101 78.90625 Surface contaminate 158 64 40.50633 Injection thermometer 776 580 74.74227 pH meter 55 53 96.36364 Hygrometer 57 36 63.15789 Aflatoxin 66 66 100 Food contamination 66 66 100

Total number of drinking water storage reservoirs 450 Inspected drinking water storage reservoirs 400 350 300 250 200 Number Number 150 100 50 0

Date Fig. 6. Drinking water reservoirs and number of inspected reservoirs per day

In the current research, the water treatment plant in Khorramshahr. Every reservoirs were polyethylene barrels, and the reservoir was inspected several times per day. Water and Wastewater Organization (ABFA) After sampling, the routine tests of drinking trucks distributed water in the Mawkebs. The water were performed on the samples for the water was used for both drinking and sanitary measurement of the free residual chlorine, pH, purposes and supplied from the water turbidity, total coliforms, and thermoduric

MUK-JAEHR J Adv Environ Health Res (2020) 8: 133-142 141 coliforms.23 Fig. 7 depicts the number of the undesirable. In most of the water reservoirs, water samples in the studied area and the residual chlorine was acceptable, and the undesirable samples. Accordingly, 46 (24.7%) inspection of chlorine was performed out of 186 water samples were considered constantly.

Total number of water samples 25 Number of water samples with undesired results

20

15

10 Number Number 5

0

Date Fig. 7. Number of water samples and their results

According to the study by Masoumbeigi medical examination cards and practice et al. regarding the bacteriological and personal hygiene as a priority. chemical water quality of some military centers, water hygiene was excellent in 60% of Funding/Support the cases, while it was moderate in 20% and This research project was financially poor in 20% of the samples. Furthermore, the supported by Abadan School of Medical mentioned study indicated that with the Sciences (contract number: 96H-369 dated 20- exception of one case, the rest of the samples 9-2018; code: IR. ABADANUMS. REC. had exceeding contents of nitrate, and the other 1397. 010). indicators of water quality control were also suitable. Previous findings and direct Acknowledgments observations have also shown that 99.9% of Hereby, we extend our gratitude to the the food, water reservoir, production, and Research Committee of Abadan School of distribution location health status and the Medical Sciences for assisting us in this health status of the crew in charge of food research project. production and distribution have been proper.15 References 1. World Health Organization (WHO). Conclusion Communicable disease alert and response for According to the results, the mass gatherings: Technical Workshop. environmental health status, food, and Geneva, Switzerland, 2008. drinking water hygiene used for Arbaeen 2. Fouladi Fard R, Mahvi AH, Hosseini SS, Khazaei M. Fluoride concentrations in bottled pilgrimage along the Shalamcheh road was drinking water available in Najaf and Karbala, proper. It is recommended that special health Iraq. Fluoride 2014; 47(3): 249-52. criteria and indicators be considered for setting 3. Available from: http://hajj.ir/fa/98438. up free service stations and all the employees 4. Sumner S, Brown LG, Frick R, Stone C, take the required training courses to obtain

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